NYHIMA 2014 Annual Conference: ICD-10 Data Analytics That Help Focus CDI Physician Training and CDI...

NYHIMA 2014 Annual Conference: ICD-10 Data Analytics That Help Focus CDI Physician Training and CDI Staff EffortsJune 3, 2014

Presented By:Kim Charland, BA, RHIT, CCSSenior Vice President Clinical InnovationPanacea Healthcare Solutions, Inc.

© 2014 Panacea Healthcare Solutions, Inc.

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• Panacea Healthcare Solutions, Inc. has prepared this seminar using official Centers for Medicare and Medicaid Services (CMS) documents and other pertinent regulatory and industry resources. It is designed to provide accurate and authoritative information on the subject matter. Every reasonable effort has been made to ensure its accuracy. Nevertheless, the ultimate responsibility for correct use of the coding system and the publication lies with the user.

• Panacea Healthcare Solutions, Inc., its employees, agents and staff make no representation, warranty or guarantee that this information is error-free or that the use of this material will prevent differences of opinion or disputes with payers. The company will bear no responsibility or liability for the results or consequences of the use of this material. The publication is provided “as is” without warranty of any kind, either expressed or implied, including, but not limited to, implied warranties or merchantability and fitness for a particular purpose.

• The information presented is based on the experience and interpretation of the publisher. Though all of the information has been carefully researched and checked for accuracy and completeness, the publisher does not accept any responsibility or liability with regard to errors, omissions, misuse or misinterpretation.

• Current Procedural Terminology (CPT ®) is copyright 2013 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

• CPT® is a trademark of the American Medical Association.• Copyright © 2014 by Panacea Healthcare Solutions, Inc. All rights reserved.

– No part of this presentation may be reproduced in any form whatsoever without written permission from the publisher

– Published by Panacea Healthcare Solutions, Inc., 287 East Sixth Street, Suite 400, St. Paul, MN, 55101

Disclaimer


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• Why ICD-10 Data Analytics?• Case Studies: ICD-10 Data Analytics Results• Top ICD-10 Diagnosis Documentation Concepts• Top ICD-10 Procedure Documentation Concepts• About 16-Months To Go……..Were Do We

Focus?

Today’s Agenda

WHY ICD-10 DATA ANALYTICS?


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• Use Your Data To Create Education Material:– Identify documentation gaps– Classify your gaps into DRGs, documentation

diagnosis and procedure concepts, specialty, and Physician

– Develop tools to aid Physicians– Education Program – General Sessions / Reporting,

Specialty Sessions, One-on-One Sessions

Why ICD-10 Data Analytics?


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ICD10monitor’s Talk Ten Tuesday Poll

June 25, 2013


Question When is your organization planning to do its coding data analytics to assess potential revenue risk?

Percent

A: We already have 25%

B: By the end of 2013 39%

C: Beginning of 2014 13%

D: We are not doing it 9%

E: What is data analytics? 14%


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Repeated poll on May 20, 2014


Question When is your organization planning to do its coding data analytics to assess potential revenue risk and develop focused documentation education?

Percent

A: We already have 38%

B: Sometime in 2014 34%

C: By June of 2015 12%

D: We are not doing it 9%

E: What is data analytics? 6%


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July 2, 2013

Financial

Question What financial impact results has your data analytics revealed?

Percent

A: Potentially less reimbursement under ICD-10 14%

B: Potentially more reimbursement under ICD-10 5%

C: Potentially remaining revenue neutral 17%

D: Still have not done 50%

E: Not applicable to my organization 14%


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Repeated poll on February 25, 2014

Financial

Question What financial impact results has your data analytics revealed?

Percent

A: Potentially less reimbursement under ICD-10 16%

B: Potentially more reimbursement under ICD-10 6%

C: Potentially remaining revenue neutral 19%

D: Still have not done 38%

E: Decided not to do it 2%

F: Not applicable to my organization 19%


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October 1, 2013


Question With one year to go, what is your biggest risk area for not being ready on October 1st, 2014?

Percent

A: Claims submission 6%

B: Payment / cash flow 13%

C: Coding staff training / productivity 20%

D: Physician documentation 47%

E: System / software / tool updates 14%


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October 29, 2013


Question How engaged are your Physicians overall with ICD-10?

Percent

A: High 4%

B: Moderate 30%

C: Low 44%

D: None, they want another delay 9%

E: Not applicable 13%


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February 4, 2014


Question When it comes to engaging Physicians at your facility, are you customizing training that fits their specialties?

Percent

A: Yes we are taking this approach 61%

B: We are considering this approach 13%

C: We have not determined our approach 9%

D: No we are not taking this approach 4%



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September 10, 2013


Question Do you have a CDI program? Percent

A: Yes, we’ve had it for years 50%

B: Yes, we’ve recently set it up 16%

C: No, but we are going to set it up 11%

D: No and we don’t plan to 7%



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September 17, 2013


Question Is your Clinical Documentation Program (CDIP) reviewing for ICD-10 yet?

Percent

A: Yes 37%

B: Not yet but planning to before end of 2013 16%

C: Not yet but planning to start in 2014 17%

D: We don’t have a CDIP 12%


CASE STUDY ICD-10 DATA ANALYTICS RESULTS


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• Perform an ICD-10 Documentation Audit to assess the completeness of Physician documentation to support ICD-10 code assignment by natively coding in ICD-10. (Inpatient, Outpatient and Physician records were included).

• Perform an ICD-9 MS-DRG Validation Audit to ensure that the estimated MS-DRG financial impact is based on a correct ICD-9 starting MS-DRG.

Case Study ICD-10 Data Analytics Results


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• Identify gaps and opportunities that are specific to your documentation in ICD-10.

• Identify financial opportunities and risks based upon MS-DRG assignment. (MS-DRG Grouper v31 was used for the MS-DRG ICD-9 and MS-DRG ICD-10 calculations)

Case Study ICD-10 Data Analytics Results


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• Inpatient Case Study 1:– IPPS Hospital– 162 Med/Surg and 12 Specialty Beds– 9,896 Annual Inpatient Discharges

• Audit Specifics:– 400 inpatient charts were natively coded in ICD-10– A data analytic tool was used to identify claims with potential

moderate to high risk based upon GEMS (General Equivalency Maps) and a proprietary software alga rhythm

– Included a balance of top Physicians identified by the software– Diagnoses and procedures that reflect high volume for potential

financial impact– Included a balance of top MS-DRGs

Inpatient Case Study ICD-10 Data Analytics Results

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Inpatient Case Study 1: Inpatient I-9 to ICD-10 MS-DRG Shift Estimated Financial Impact

MS-DRG Shift Change Reason

# of Changes Identified

% of Claims Change

Estimated Financial Impact

Principal Diagnosis Causing DRG Shift

22 5.5% ($2,470)

Secondary Diagnosis Causing DRG Shift

45 11.25% ($25,258)

Principal Procedure Causing DRG Shift

36 9% ($25,010)

Principal Diagnosis and Procedure Causing DRG Shift

1 0.25% $4,466

Incomplete Physician Documentation

5 1.25% ($3,987)

Total Estimated Financial Impact

109 ($52,259)


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• A total of 4,564 ICD-10-CM diagnosis codes were coded:

Inpatient Case Study 1: ICD-10 Diagnosis Coding Statistics

ICD-10 Reason Code Number of Codes

Percent

Specified code in ICD-10 assigned 3,527 77.3%

Unspecified code in ICD-10 assigned

1,027 22.5%

Could not be coded in ICD-10 10 <1%


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• A total of 693 ICD-10-PCS procedure codes were coded:

Inpatient Case Study 1: ICD-10 Procedure Coding Statistics


Percent

Specified code in ICD-10 assigned 670 96.7%


3 <1%

Could not be coded in ICD-10 20 2.9%



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• Inpatient Case Study 2:– IPPS Hospital– 235 Med/Surg and 75 Specialty Beds– 20,137 Annual Inpatient Discharges






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% of Claims Change



33 8% ($35,139)


32 8% ($38,917)


46 12% $8,076

Principal Diagnosis and Procedure Causing DRG Shift

2 0.5% $5,680

Incomplete Physician Documentation caused the MS-DRG shift

3 0.8% $763


113 ($59,537)


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Percent



1127 21.1%

Not able to code in ICD-10 29 0.5%


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• A total of 1,333 ICD-10-PCS procedure codes were coded:



Percent



49 3.7%



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• Inpatient Case Study 3:– IPPS Hospital– 88 Med/Surg and 12 Specialty Beds– 5,419 Annual Discharges






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% of Claims Change



10 10% $7,796


9 9% ($16,685)


8 8% $26,971

Incomplete Physician Documentation caused the MS-DRG shift

2 2% $0


29 $18,082


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Percent

Specified code in ICD-10 assigned 989 82%


220 18%


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• A total of 200 ICD-10-PCS procedure codes were coded:



Percent

Specified code in ICD-10 assigned 193 97%


7 3%



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• Physician Case Study 1:– OPPS Hospital– 36 Hospital-based Clinics

• Audit Specifics:– 290 physician encounters (original plan was 600)– Diagnosis focus only– A data analytic tool was used to identify claims with potential

primary code movement based upon GEMS (General Equivalency Maps) and a proprietary software alga rhythm

– Include a balance of top Physicians identified by the software– Include a sample of high volume specialties identified by the

software– Include “unspecified” codes

Physician Case Study ICD-10 Data Analytics Results

• 967 ICD-10 diagnosis codes were coded:

Physician Case Study 1:ICD-10-CM Physician Audit Results


ICD-10 Reason Code Percent

Specified code in ICD-10 assigned 63%

Unspecified code in ICD-10 assigned 36%

Could not be coded in ICD-10 1%


• Chapters with the highest percentage of specified codes:

Physician Case Study 1:Physician Trends by ICD-10-CM Chapter

ChapterICD-10-CM Specified

Code

Specialties Impacted

Infectious Disease 83% FPInjuries and Poisoning 84% FPFactors Influencing Health Factors (Z-Codes) 88%

Endo, FP, IM, Pulm, Rheum

• Chapters with the lowest percentage of specified codes:

Physician Case Study 1:Physician Trends by ICD-10-CM Chapter

ChapterICD-10-CM

Specified CodeSpecialties Impacted

Skin 37% FP, IMNeurology 42% FP, IM, SleepRespiratory 43% FP, IM, PulmonologyMental Health 45% FP, IM, PsychObstetrics 50% OB


Physician Case Study1:Physician ICD-10-CM Trends by Specialty

Specialty Percentage Specified

Pulmonology 83%Endocrinology 80%Cardiology 78%Obstetrics 67%Family Practice 62%Rheumatology 61%Internal Medicine 57%Sleep Medicine 44%Psychiatry 30%


TOP ICD-10 DIAGNOSIS DOCUMENTATION CONCEPTS

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• Background: In ICD-9-CM, two codes are required to report the diagnosis of sepsis (septicemia, 038.9 and sepsis 995.91 or severe sepsis, 995.92 dependent upon with or without organ dysfunction). An additional code is also assigned for septic shock (severe sepsis). In ICD-10, a diagnosis of sepsis unspecified is assigned as A41.9. An additional code is assigned for severe sepsis or an associated acute organ dysfunction noted. Severe sepsis is classified as with or without septic shock.

• Specialties Most Affected: Hospitalist, Internal Medicine, Infectious Disease

ICD-10-CM Diagnosis Concept 1: Sepsis


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• Finding: The review showed sufficient documentation of sepsis present in about half of the records reviewed.

• Recommendation: In ICD-10, the physician must still continue to document the disorder of sepsis, as well as acute organ dysfunction (severe sepsis) if applicable. Documentation of septic shock is still needed if appropriate. The causative organism along with the source of the sepsis such as pneumonia, urinary tract infection, cellulitis, post-procedural ,etc. needs to be documented as well. Sepsis should also be clearly documented regarding present on admission status.

ICD-10-CM Diagnosis Concept 1: Sepsis


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• Background: Although ICD-10 allows for an unspecified site, the code set expands malignant neoplasms of most body organs/systems to specific sites requiring documentation of the specific site and laterality.

• Specialties Most Affected: Hospitalist, Internal Medicine, Oncology

• Finding: Neoplasm documentation was not sufficient in some of the records reviewed to be able to code to a specific location of the neoplasm, most notably colon, stomach, lung, kidney, bladder and breast.

• Recommendation: The provider must document the specific location of the neoplasm as well as the laterality--primary or metastatic. In ICD-10 many of the organs have been expanded to include more specific locations within that organ. For example, lung has been expanded to include the laterality and region (upper/middle/lower) for the neoplasm.

ICD-10-CM Diagnosis Concept 2: Neoplasm


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• Background: The coding guidelines for anemia have been revised for ICD-10. – ICD-10 Guideline, Chapter 2 c. 1: When the admission is for

management of the anemia associated with malignancy or a chronic disease, and the treatment is only for the anemia, the diagnosis code for the malignancy or chronic disease is sequenced as the principal diagnosis followed by the appropriate code for the anemia.

– ICD-9 Guideline not present in ICD-10: If anemia in neoplastic disease and anemia due to antineoplastic chemotherapy are both documented, assign codes for both conditions.

– ICD-10: Anemia due to chemotherapy and anemia in neoplastic disease have excludes 1 notes.

ICD-10-CM Diagnosis Concept 3: Anemia


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• Specialties Most Affected: Hospitalist, Internal Medicine, Oncology, Hematology

• Finding: The MS-DRG assignment is revised for those patients admitted due to anemia of chronic disease. Clarification is needed regarding anemia due to chemotherapy vs. anemia due to neoplastic disease due to the excludes 1 note.

• Recommendation: Documentation by the physician is needed to clearly state the specificity of the anemia, such as anemia due to neoplasm or chronic kidney disease. The specificity of the anemia is essential for appropriate code assignment.

ICD-10-CM Diagnosis Concept 3: Anemia


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• Background: As in ICD-9, thrombocytopenia can be further specified such as primary, secondary, idiopathic, due to drugs, etc.

• Specialties Most Affected: Hospitalist, Internal Medicine, Hematology

• Findings: Many of the records reviewed did not contain the specificity of the thrombocytopenia.

• Recommendation: Providers should document the specificity of thrombocytopenia to appropriately classify this disorder. The specificity of thrombocytopenia may be considered a CC status diagnosis.

ICD-10-CM Diagnosis Concept 4: Thrombocytopenia


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• Background: ICD-10 has expanded its diabetes mellitus to include combination codes which include the manifestation; therefore, coding multiple codes is no longer required. However, documentation of the manifestation is required to select the principal diagnosis. Diabetes noted as out of control, poorly controlled, or inadequately controlled denotes diabetes with hyperglycemia.

• Specialties Most Affected: Hospitalist, Internal Medicine

• Finding: The review showed that most diabetes codes were documented appropriately. There were a few in which the documentation could have been more specific.

• Recommendation: Providers should continue to document the type of Diabetes as Type I or Type 2 and the specific manifestations. Diabetic ulcers require additional documentation to identify the depth of the ulcer (e.g., breakdown of skin, fat). Physicians should continue to document hyper- and hypoglycemia.

ICD-10-CM Diagnosis Concept 5: Diabetes


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• Background: As in ICD-9 malnutrition can be further specified to the degree such as mild, moderate, or severe protein-calorie malnutrition.

• Specialties Most Affected: Hospitalist, Internal Medicine• Finding: Many of the records reviewed only had

documentation of unspecified malnutrition.• Recommendation: Malnutrition should be specified to

the appropriate degree such as mild, moderate, or severe protein-calorie with or without marasmus and/or kwashiorkor. The specificity of malnutrition can affect the MCC/CC status of this diagnosis.

ICD-10-CM Diagnosis Concept 6: Malnutrition


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• Background: Drug dependence in ICD-10 is no longer classified as unspecified, continuous or episodic use. Drug dependence is specified with disorders such as intoxication, mood, psychotic, sleep, etc. Remission status is still a classification. Drug dependence, uncomplicated, such as opioid, is now considered a CC status diagnosis. Drug use and abuse are also now separately identified.

• Specialties Most Affected: Hospitalist, Internal Medicine, Psychiatry

ICD-10-CM Diagnosis Concept 7: Drug Dependence


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• Finding: Many of the records reviewed were related to opioid dependence and triggered MS DRG status changes due to the CC status change.

• Recommendation: Documentation by the physician should clearly note the specific drug and classification of use, abuse, dependence, or in remission. Also any associated disorders should be clearly noted. The specificity of use, abuse, dependence, or remission may affect the CC status of the diagnosis.

ICD-10-CM Diagnosis Concept 7: Drug Dependence


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• Background: Documentation for depressive disorders in ICD-10 requires inclusion of the type of episode (recurrent, in remission, or single episode), degree of severity (mild, moderate, severe) and with psychotic features if applicable. If in remission, the provider must state “in remission” as this cannot be inferred. If the patient is in remission, the provider must also state whether it is partial or full remission. Depression not otherwise specified is now classified as major depressive disorder, single episode.

• Specialties Most Affected: Hospitalist, Internal Medicine, Emergency Medicine, Psychiatry

ICD-10-CM Diagnosis Concept 8: Depression/Major Depressive Disorder


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• Finding: The review showed that many of the depression codes did not provide the type, severity or status of the depression.

• Recommendation: The provider should document the type of depression, single vs. recurrent, degree of severity, and document if associated conditions and/or complications are present. If the patient is in remission, this must be documented and cannot be inferred. Major depressive disorder, single, with at least mild severity is considered a CC status diagnosis. Major depressive disorder, recurrent, is also considered a CC status diagnosis.

ICD-10-CM Diagnosis Concept 8: Depression/Major Depressive Disorder


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• Background: There have been coding guideline changes associated with myocardial infarction diagnosis and the physician must provide specificity as to the site, type, and age of the myocardial infarction. There are changes to the subsequent AMI coding guideline in ICD-10. A code for subsequent AMI is to be used when a patient has suffered a new AMI within a four week time period of the initial AMI.

• ICD-10 Guideline, Chapter 9 e. 1): For encounters occurring while the myocardial infarction is equal to, or less than, four weeks old, including transfers to another acute setting or a post-acute setting, and the patient requires continued care for the myocardial infarction, codes from category I21 may continue to be reported.

ICD-10-CM Diagnosis Concept 9: Myocardial Infarction


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• Specialties Most Affected: Hospitalist, Internal Medicine, Cardiology• Finding: The review showed that many of the records had adequate

documentation of the age of the MI as well as location. • Recommendation: Recommend that documentation of the myocardial

infarction continue to be specified as to the site, type and date of the acute infarction. This would also include patients that are transferred to this hospital so that the correct coding can be applied based on the coding guideline change. It is recommended that documentation of AMI continue to be specific as to the type of acute or subsequent acute, and clearly document the date of the AMI so the coding professional can determine if this is a new AMI, an AMI within the four week period, including transfers, and the patient requires continue care, or a new AMI within the four week time period from an initial AMI.

ICD-10-CM Diagnosis Concept 9: Myocardial Infarction


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• Background: Atrial fibrillation has been expanded in ICD-10 to include the type of atrial fibrillation. The new documentation elements include paroxysmal, persistent, and chronic.

• Specialties Most Affected: Hospitalist, Internal Medicine, Cardiology

• Finding: Many of the records reviewed did not contain documentation of the type of atrial fibrillation.

• Recommendation: Providers should review new documentation elements for category I48, Atrial Fibrillation. To code a specified code, documentation should include chronic, persistent or paroxysmal. Persistent atrial fibrillation is considered a CC status diagnosis.

ICD-10-CM Diagnosis Concept 10:Atrial Fibrillation


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• Background: Hypertension as identified in ICD-9 is classified as either accelerated/malignant or benign. In ICD-10 the classification will only consist of one code and include both benign and accelerated/malignant. Accelerated/malignant is now considered a non-essential modifier and no longer a CC status diagnosis.

• Specialties Most Affected: Hospitalist, Internal Medicine, Cardiology, Emergency Medicine

• Finding: A few of the records reviewed contained documentation of accelerated/malignant hypertension which is no longer recognized as a CC status diagnosis.

• Recommendation: Providers should be encouraged to continue to document the type of hypertension as determined during the treatment of the patient. If there is a cause and effect relationship with hypertension and other disorders such as heart disease or cardiorenal disease these should continue to be documented as well.

ICD-10-CM Diagnosis Concept 11: Hypertension


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• Background: As in ICD-9, the specificity and degree of the heart block should be clearly documented. AV block type II is no longer considered a CC status diagnosis in ICD-10. However, there is a classification change in ICD-10 regarding bundle branch blocks with fascicular block that may result in a CC status diagnosis.

• Specialties Most Affected: Hospitalist, Internal Medicine, Cardiology

• Findings: As a result of the coding change, a record was found to have a CC status change with the AV block type II no longer being a CC.

• Recommendation: Documentation of heart block specificity such as atrioventricular, bundle branch, bifascicular, etc. should be clearly noted along with the degree such as first, second, third, etc. for accurate and complete code assignment. The specificity of the heart block may affect the MS DRG assignment in ICD-10 coding.

ICD-10-CM Diagnosis Concept 12: Heart Block


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• Background: Like in ICD-9, in order to code congestive heart failure to the highest level of specificity, providers must document whether the heart failure is left ventricular, systolic, diastolic or combined. In addition, the documentation should state acute, chronic or acute on chronic. ICD-10 has a combination code for congestive heart failure noted as systolic, diastolic or combined. A secondary code of congestive heart failure is no longer required as congestive is considered a non-essential modifier with the specificity.

• Specialties Most Affected: Hospitalist, Internal Medicine, Cardiology, Emergency Medicine

• Findings: Many of the records reviewed contained documentation as to the type of acuity of congestive heart failure.

• Recommendation: Providers should continue to document the acuity (acute, chronic or acute on chronic) and type (diastolic, systolic or combined) of heart failure. Also linking any related or underlying conditions such as hypertensive heart disease or cardiomyopathy is also needed.

ICD-10-CM Diagnosis Concept 13: Congestive Heart Failure


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• Background: Pulmonary embolism has been expanded in ICD-10 to now include the option of this condition with acute cor pulmonale as a combination code. The type of embolism such as septic or saddle should also be documented as well. If the pulmonary embolism is a complication of a procedure, clear documentation of this relationship needs to be noted.

• Specialties Most Affected: Hospitalist, Internal Medicine, Surgery, Cardiology

• Findings: Acute cor pulmonale was documented on a few of the records and with the conversion to ICD-10 coding the acute condition is now classified with pulmonary embolism rather than classified separately.

ICD-10-CM Diagnosis Concept 14: Pulmonary Embolism/Acute Cor Pulmonale


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• Recommendation: Providers should continue to clearly identify the acuity of the pulmonary embolism (acute, chronic or history of) as well as the acuity of cor pulmonale (acute or chronic). Documentation of the underlying cause of the pulmonary embolism is necessary and if the embolism is a complication of a procedure, the cause and effect must be clearly noted. The MS DRG is affected due to the principal diagnosis of acute cor pulmonale and pulmonary embolism if specified as a complication of a procedure.

ICD-10-CM Diagnosis Concept 14: Pulmonary Embolism/Acute Cor Pulmonale


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• Background: ICD-10 has greatly expanded the category of cerebral infarctions to include the exact site of the infarction, laterality and whether or not it is a thrombosis, an embolism ,or hemorrhage that has caused the infarction.

• Specialties Most Affected: Hospitalist, Internal Medicine, Neurology

• Findings: A few of the records review did contain documentation of the exact site of the cerebral infarction.

• Recommendation: Providers should continue to document the exact site of the cerebral infarction (vertebral, carotid, basilar, cerebral etc.), laterality, the specific vessel in which the infarction occurred and whether or not it is thrombotic, embolic ,or hemorrhagic in nature.

ICD-10-CM Diagnosis Concept 15: Cerebral Infarction


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• Background: ICD-9 has multiple codes to reflect COPD noting if the patient is in acute exacerbation, whether it is due to other obstruction conditions and if the disorder is associated with bronchitis, asthma emphysema, etc.

• Bronchitis has been expanded to facilitate identification of secondary disease processes, specific manifestations or associated complications in ICD-10. Chronic bronchitis can also be further defined to include specificity such as asthmatic, obstructive, purulent, etc.

• ICD-10 expands asthma to include severity (mild, moderate and severe) as well as intermittent or persistent. New guidelines now require an additional code for tobacco use and/or exposure, if applicable.

• Specialties Most Affected: Hospitalist, Internal Medicine, Pulmonary, Pediatrics, Emergency Medicine

ICD-10-CM Diagnosis Concept 16: COPD/Bronchitis/Asthma


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• Findings: Many of the records reviewed did not state whether the patient was in acute exacerbation or any other type of obstructive condition with the documentation of COPD.

• Many of the bronchitis codes reviewed did not contain the specificity needed to be able to code further than unspecified bronchitis in ICD-10. Chronic bronchitis was documented but no further specificity as to whether it was obstructive, asthmatic, etc.

• Many of the records reviewed did not specify the severity of the asthma.



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• Recommendation: Providers should continue to clearly document the type of obstructive disease with the diagnosis of COPD and if the patient is in acute exacerbation.

• Providers should continue to document the causative organism (when known) for acute bronchitis so that further classification can be coded. Chronic bronchitis should be further specified, if known, to include asthmatic, obstructive, purulent, etc.

• Providers should document severity and state intermittent or persistent as well as any exacerbation or status asthmaticus. Additionally, tobacco use or exposure is now a required documentation element for asthma if applicable.



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• Background: As in ICD-9, codes for hepatitis in ICD-10 specify whether the condition is acute or chronic and whether it is with or without hepatic coma.

• Hepatic encephalopathy has been expanded in ICD-10 to include acuity (acute/chronic) and whether it is with or without coma.

• Specialties Most Affected: Hospitalist, Internal Medicine, Gastroenterology

• Findings: Some of the records reviewed did not have documentation of whether the hepatitis was acute or chronic. The type of hepatitis (A, B, C) was documented. Some of the records did not document the acuity or if the patient was with or without coma.

• Recommendation: Providers should continue to document the type of hepatitis as well as the acuity of this condition. Providers should also continue to document the type of encephalopathy and include the acuity and if it is with or without coma. The specificity of with or without coma affects the MCC/CC status of this diagnosis.

ICD-10-CM Diagnosis Concept 17: Hepatitis/Hepatic Encephalopathy


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• Background: ICD-10 coding for decubitus/pressure ulcer diagnosis is identified by one combination code which specifies the site of the ulcer and the stage of the ulcer instead of two codes that were needed in the ICD-9 classification.

• Specialties Most Affected: Hospitalist, Internal Medicine, Surgery

• Findings: Some of the records reviewed did not specify the depth or type of breakdown that was present on non-pressure ulcers..

• Recommendation: Providers must document the specific type, site and stage of the pressure ulcers. Distinct documentation of the present on admission status must also accompany any type of pressure ulcer documentation as this can be considered a hospital acquired condition. With non-pressure ulcers, documentation must include the location of the ulcer, laterality and the level of involvement to include breakdown of skin, with fat layer exposed, with necrosis of muscle and with necrosis of bone.

ICD-10-CM Diagnosis Concept 18: Skin Ulcer


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• Background: As in ICD-9, chronic kidney disease can be further specified as stage 1 through 5 or end stage renal disease. If hypertension is also specified, an additional code is assigned for hypertensive chronic kidney disease.

• Specialties Most Affected: Nephrology, Internal Medicine, Hospitalist, Urology

• Findings: Many of the records reviewed did not have the stage of the chronic kidney disease documented.

• Recommendation: Physician documentation should be specific to identify the stage of the chronic kidney disease or end stage renal disease. The stage of chronic kidney disease or end stage renal disease reflects the severity of this disorder. The stage of chronic kidney disease can also affect the MCC/CC status of the diagnosis.

ICD-10-CM Diagnosis Concept 19: Chronic Kidney Disease


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• Background: Urinary retention in I-10 now includes if it is drug induced. The additional code for adverse effect, if applicable, to identify the drug is also coded.

• Specialties Most Affected: Hospitalist, Internal Medicine, Urology

• Findings: The records reviewed did not document the type of urinary retention.

• Recommendation: Physician documentation should include the specificity of urinary retention such as due to hyperplasia of the prostate, psychogenic, organic or drug induced. The additional code to identify the drug for adverse effect, if applicable, should also be documented.

ICD-10-CM Diagnosis Concept 20: Urinary Retention


TOP ICD-10 PROCEDURE DOCUMENTATION CONCEPTS

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• Background: Excisional debridement of skin and subcutaneous tissues in ICD-10 is classified as separate body systems vs. the same classification when compared to ICD-9 coding. The body part is also site specific and includes laterality of right and/or left when applicable. There are also approach options for the subcutaneous tissues and qualifier of diagnostic, if appropriate.

• Specialties Most Affected: Surgery, Wound Care, Hospitalists, Emergency Medicine, Internal Medicine

• Findings: Some of the records reviewed did not contain documentation as to whether the debridement was excisional or non-excisional, to what level of tissue was debrided and site where the debridement took place.

ICD-10 Procedure Concept 1: Debridement


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• Recommendation: Physician documentation for debridement must be specific to the body system involved (skin, subcutaneous tissue, fascia, muscle, bone, etc.) and to the specific body part undergoing the debridement procedure. The approach must be noted as to whether it is open or percutaneous per the ICD-10 definitions. Laterality of right or left is also necessary. If the procedure is diagnostic in nature this needs to be documented as well. The specificity of the procedure can affect the MS DRG assignment.

ICD-10 Procedure Concept 1: Debridement


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• Background: ICD-10 has separate body systems for skin and subcutaneous tissue. Along with specifying the depth of the incision, the specific body part (scalp, face, ear, neck, chest, back, abdomen, buttock, perineum, genitalia, arm, hand, leg, foot, nail, breast, nipple) and the laterality of that body part must be documented.

• Specialties Most Affected: Surgery, Emergency Medicine, Hospitalists, Internal Medicine

• Findings: Some of the records reviewed did not contain the depth of incision.

• Recommendation: Physician documentation will need to specify the depth of the incision, the specific body part (skin vs. subcutaneous tissue), laterality and if any drainage device was left in place to adequately code these procedures in ICD-10. The specificity of the procedure can affect the MS DRG assignment.

ICD-10 Procedure Concept 2: Incision & Drainage


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• Background: ICD-10 classifies amputation to the root operation of “Detachment” and further defines the body part in which the amputation is being performed on. Laterality and the level of the procedure being performed and noting whether the amputation is of a high, mid or low in nature is important in classifying these procedures.

PCS Reference Manual: Upper arm and upper leg – Qualifier 1 High: Amputation at the proximal portion of the shaft of the

humerus or femur – Qualifier 2 Mid: Amputation at the middle portion of the shaft of the

humerus or femur – Qualifier 3 Low: Amputation at the distal portion of the shaft of the

humerus or femur

ICD-10 Procedure Concept 3: Amputation


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• Specialties Most Affected: Orthopedics, Vascular Surgery

• Findings: Some of the records reviewed did not contain the level of the amputation and could not be coded due to this missing documentation.

ICD-10 Procedure Concept 3: Amputation


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• Background: ICD-10 is specific to the objective or root operation of the procedure, body part and device along with the approach for the procedure of EGD with banding of esophageal varices.

• Specialties Most Affected: Gastroenterology

• Findings: Two MS DRG changes were identified as a result of this procedure.

• Recommendation: Continue to document the objective or root operation of the procedure (i.e., occlusion), approach, body system and body part of lower vein, esophageal, and device (band). This is currently considered a procedure that affects MS DRG assignment. Also reference AHA Coding Clinic 4th Quarter 2013, page 112 – 113 for details.

ICD-10 Procedure Concept 4: Banding of Esophageal Varices


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• Background: ICD-10 is specific to the section or general type of the procedure, body system, objective or root operation of the procedure, body part, approach, device and qualifier for the procedure for thrombectomy of AV fistula.

• Specialties Most Affected: Vascular Surgery

• Findings: The artery or vein that the procedure was being performed in was not documented.

• Recommendation: Specific documentation is needed to describe the thrombectomy procedure of the AV fistula to include thrombectomy of the artery/vein involved. The specific artery such as brachial or radial, and/or vein such as basilica or brachial is also required. Laterality of right and left is also specified in the body part.

ICD-10 Procedure Concept 5: AV Fistula Thrombectomy


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• Background: Revision of joint procedures in ICD-10 now require two codes, one for the removal of the previous prosthesis material and one for the replacement. The approach, laterality, specific component, and substitute material along with the specificity of it being cemented or uncemented are now required.

• Specialties Most Affected: Orthopedics

• Findings: The documentation of the type material inserted was not able to be located.

• Recommendation: Physician documentation must include the specific joint components being replaced, laterality, approach, substitute materials and whether these components are cemented or uncemented. The joint procedures currently can cause movement in the ICD-10 MS DRG assignment; however, it appears to be an error in the grouping logic.

ICD-10 Procedure Concept 6: Revision of Joint Replacement


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• Background: In ICD-10, procedures on the bowel now must include the specific portion of the bowel that the procedure is being performed on. For the large bowel this would include the specific parts of sigmoid, ascending colon, descending colon, transverse colon, rectum, etc. For the small bowel this would include the specific parts of jejunum, duodenum, ileum, etc. Documentation must also include whether all (resection) or a portion of the body part (excision) is being removed as the root operation is different depending on all or a portion of the specified bowel. Documentation of the approach is also needed to know whether it was open, percutaneous endoscopic, etc.

• Specialties Most Affected: Surgery

ICD-10 Procedure Concept 7: Bowel Procedures


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• Findings: The documentation of the specific area in which the procedure was being performed was not readily identifiable in all cases reviewed.

• Recommendation: Physician documentation must be specific as to which portion of the small or large bowel the procedure is being performed on, whether all or a portion of the bowel is being removed and the approach of the procedure. The specific site of the procedure in the large or small bowel may have an effect on the MS DRG assignment for the case.

ICD-10 Procedure Concept 7: Bowel Procedures


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• Background: In ICD-9, lysis of adhesions was represented by one procedure code, i.e. intestine. In ICD-10 this procedure is now coded to the specific location of the adhesions and the number of code possibilities has dramatically increased. The physician also needs to document the approach that was taken to correctly code these procedures.

• Specialties Most Affected: Surgery, Gynecology

• Findings: The documentation of the specific area in which the procedure was performed was present in most of the records reviewed.

• Recommendation: Physician documentation must be specific for the location of the lysis of adhesions so that the appropriate procedure can be coded. The approach should also be documented. This procedure may affect the MS DRG assignment.

ICD-10 Procedure Concept 8: Lysis of Adhesions


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• Background: Coding guidelines have changed in ICD-10 for the coding of PTCA procedures. ICD-9 referenced the number of coronary vessels treated. ICD-10 guidelines now specify the number of sites treated rather than the name or number of arteries.

• ICD-10-PCS Guideline, B4.4: The coronary arteries are classified as a single body part that is further specified by number of sites treated and not by name or number of arteries. Separate body part values are used to specify the number of sites treated when the same procedure is performed on multiple sites in the coronary arteries.

ICD-10 Procedure Concept 9: PTCA


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Examples: Angioplasty of two distinct sites in the left anterior descending coronary artery with placement of two stents is coded as Dilation of Coronary Arteries, Two Sites, with Intraluminal Device.

Angioplasty of two distinct sites in the left anterior descending coronary artery, one with stent placed and one without, is coded separately as Dilation of Coronary Artery, One Site with Intraluminal Device, and Dilation of Coronary Artery, One Site with no device.• Specialties Most Affected: Cardiology• Findings: The documentation of the number of sites treated was present in

most of the records reviewed.• Recommendation: Physician documentation needs to describe the details

of the procedure performed as well as the number of site treated and the types of stents inserted. Panacea recommends a dictated procedure note in addition to the signed catheterization procedure log.

ICD-10 Procedure Concept 9: PTCA


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• Background: ICD-10 requires the coding of the type of contrast material used to be included into the code selection.

• Specialties Most Affected: Cardiology

• Findings: Documentation of the type of contrast was present on the heart catheterization log but was not adequately documented to know what type of contrast (high or low osmolar) was administered. An internet search had to be performed to know whether this was high or low osmolar contrast to code these procedures correctly.

• Recommendation: Documentation should be evaluated to determine how to easily have the coding professional be able to know whether high or low osmolar contrast was administered without an impact on coding productivity as this is now a required component of the code.

ICD-10 Procedure Concept 10: Coronary Arteriogram


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• Background: ICD-10 is specific to the section or general type of the procedure, body system, objective or root operation of the procedure, body part, approach, device and qualifier for bronchoscopy with procedures such as biopsy, BAL, removal of mucous plug, etc.

• Specialties Most Affected: Pulmonology

• Findings: MS DRG changes were noted in the review as a result of mucous plug being removed as well as BAL procedures.

ICD-10 Procedure Concept 11: Bronchoscopy


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• Recommendation: Physician documentation is critical to describe the multiple procedures performed during bronchoscopy such as biopsy of bronchus or lung, BAL, removal of mucous plug, etc. The site specificity of each procedure performed, such as bronchus or lung, upper or lower, or right or left is essential to accurately code all procedures performed. The objective or root operation of each procedure can be described as excision, drainage or extirpation to denote multiple procedures performed during the bronchoscopy procedure. The specific procedures performed can affect the MS-DRG assignment.

ICD-10 Procedure Concept 11: Bronchoscopy


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• Background: ICD-10 is specific to the section or general type of procedure, body system, objective or root operation of the procedure, body part, approach, device and qualifier for manual removal of retained placenta and for repair of obstetrical lacerations. Procedures performed on the products of conception are coded to the Obstetrics section.

• Specialties Most Affected: Obstetrics

• Findings: DRG changes were noted when the removal of a retained placenta was performed or when the patient had a 3rd or 4th degree perineal laceration repaired during delivery.

• Recommendation: Documentation by the physician should include the approach used, via natural or artificial opening or with an endoscope, for the extraction of the retained products of conception and the repair of obstetrical lacerations. Currently these are considered procedures that affect the MS-DRG assignment.

ICD-10 Procedure Concept 12: Obstetrical Procedures


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• Background: ICD-10 is specific to the section or general type of the procedure, body system, objective or root operation of the procedure, body part, approach, device and qualifier for the placement of a central line.

• Specialties Most Affected: Internal Medicine, Hospitalist• Findings: ICD-10 requires coding where the catheter tip resides.

This was very difficult to locate in many of the records in which central lines were placed.

• Recommendation: Physician documentation must include where the catheter tip resides such as superior vena cava, right atrium, subclavian vein and the approach that was used to place the device. The site specificity can affect the MS DRG assignment. Reference AHA Coding Clinic Third Quarter 2013, page 18.

ICD-10 Procedure Concept 13: Central Line


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• Background: ICD-10 is specific to the section or general type of the procedure, body system, objective or root operation of the procedure, body part, approach, device and qualifier for the EGD with biopsy procedure.

• Specialties Most Affected: Gastroenterology

• Findings: The site of the biopsy in the esophagus was not documented.

• Recommendation: The documentation should specify the exact location of the biopsy procedure performed such as upper, middle, lower or esophagogastric junction. Continue to document the approach of the procedure.

ICD-10 Procedure Concept 14: EGD with Biopsy


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• Background: ICD-10 has separate body systems for skin and subcutaneous tissue vs. the same classification when compared to ICD-9 coding. The body part is also site specific and includes laterality of right and/or left when applicable. There are also approach options as well.

• Specialties Most Affected: Emergency Medicine, General Surgery, Hospitalist, Internal Medicine

• Findings: The specific depth of the tissue repaired was not documented.

• Recommendation: It is essential that the documentation is specific to the depth of tissue being repaired such as skin, subcutaneous, fascia, muscle, etc. along with the specific body site of the repair documented. Repair of the subcutaneous tissue and/or fascia can affect the MS DRG assignment.

ICD-10 Procedure Concept 15: Suture of Skin/Tissue


ABOUT 16-MONTHS TO GO……..WHERE DO WE FOCUS?

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• Address medical record documentation from an EHR perspective (what is and isn’t needed anymore, update bylaws)

• Address discharge summary and operative note writing

• All reporting of coded data is impacted by Physician documentation (documentation is not just for ICD-10)

Working With Physicians



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• Incomplete documentation means unspecified ICD-10-CM diagnosis codes (potential non-payment related to medical necessity)

• Potentially unable to code ICD-10-PCS procedure codes

• Address quality scores with Physician and how documentation impacts their scores (SOI and ROM) – “what’s in it for them”

• Physician quality scores impact patient’s decisions for where they chose to get their healthcare

Working With Physicians

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• Live communication vs. electronic queries – what do your Physicians prefer? (Workstations on wheels)

• Friendly competition among Physicians is good, post I-10 clarification results

• Decide on what you are going to “query” for ICD-10 as queries will increase (unspecified vs specified diagnosis codes)

• Procedures will need to be added to the query process

• Communication of queries to HIM Coding staff will be imperative so HIM does not repeat what has already been done – a single universal query work list that is accessible by CDI and HIM

CDI Program Tips


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• Identify top I-10 queries and track by Physician – track improvement and post results

– Type of clarification/query

– Physician

– Response type

– Financial impact

• If a Physician does not respond to a query after two attempts – contact your Physician Advisor

• Report at Medical Staff meetings

• Formal bi-weekly calls with Physician Advisor

CDI Program Tips



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• Clinical Documentation Improvement Program– Staffing and productivity

• One CDS for every 1,900 annual discharges

– Historically just DRG-based payers, moving to all patients

– Work flow / responsibilities– Tools / reporting– Assess query rates as they will increase (procedure

queries now)– Physician involvement

CDI Program Tips


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• Work with Physicians on “Documentation” in general…….QUALITY

• Address EHR templates that can assist Physicians

• Physician documentation tools• Physician Advisor• CDI Role• What Will You Query For?• CDI Reporting

In Summary……….

NYHIMA 2014 Annual Conference: ICD-10 Data Analytics That Help Focus CDI Physician Training and CDI...

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